PGY 2&3 Psychotherapy seminar 2011-2012

Bernadette Grosjean MD

Harbor UCLA

Elliott Erwitt 1953

Attachment theory is the joint work of John Bowlbyand Mary Ainsworth (1991 ).

Drawing on concepts from ethology, cybernetics, information processing, developmental psychology, and psychoanalysts, John Bowlby formulated the basic tenets of the theory.

He revolutionized our thinking about a child’s tie to the mother and its disruption through separation, deprivation, and bereavement.

Evolutions…

Ernest Jones (1879-1958)

Psychoanalysis in Britain

The London Psychoanalytical Society was founded by Ernest Jones on 30th October 1913.

Through its work – and the work of its individual members –the British Psychoanalytical Society has made an unrivalled contribution the understanding and treatment of mental illness. Members of the Society have included Michael Balint, Wilfred Bion, John Bowlby, Anna Freud, Melanie Klein, Joseph Sandler, and Donald Winnicott.

The British medical association recognized psychoanalysis in 1929

Evolutions…. March 1938 Anschluss June 1938 Freud (1856-1939) and his

family decide to go into exile “to die in freedom” and moved to London

23 September 1939, Max Schur, Freud friend and doctor administered 3 doses of morphine over a few hours which resulted in Freud death

He was cremated and his ashes repose in an ancient Greek urn gift of Marie Bonaparte with Martha's (1951) in the Golden Green Crematorium with later Anna Freud (1982) and several other members of his family

Melanie Klein (Vienna 1882-London1960)

Born in Vienna, analyzed by Sandor Ferencziduring first world war.

Became a psychoanalyst and began analyzing children in 1919

After another analyze with Karl Abraham in Berlin she was invited by Ernest Jones to come to London in 1926 where she worked until her death.

As a divorced woman (with a tragic and difficult life full of losses and conflict including with own daughter Melitta) having as only degree a teaching degree, Klein was looked at as an iconoclast within a profession dominated by male physician

Melanie Klein

She questioned some of the fundamental assumptions of Freud and offered a radical alternative to the classical perspectives regarding both severe mental disorders and early child development.

She was the first person using traditional psychoanalysis with young children (as young as 2y/o).

Melanie Klein (1882-1960)

She was innovative in both her techniques (such as working with children using toys) and in her theories in infant development.

She saw children’s play as their primary mode of emotional communication

After exploring ultra aggressive phantasies of hate, envy and greed in very young, very ill children she proposed a model of psyche that linked significant oscillation of state (replacing Freud hypothesis of Eros and Thanatos drives)

Melanie Klein (1882-1960)

She named the state of the psyche, when the sustaining principle of life is in domination “the depressive position”, and the state corresponding to the disintegrating tendency of life the ‘”paranoid-schizoid” position

Klein insisted on regarding aggression as an important force in its own right when analyzing children which brought her in conflict with Anna Freud.

She is considered as one of the founder of object relation theory

Melanie Klein (1882-1960)

Kleinien analysis with adult focuses on interpreting very deep and primitive emotions and fantasies

Today Kleinien psychoanalysis is one of the major school of psychoanalysis (Britain, much of Latin America, Europe and in the US the Psychoanalytical center of California is the major training center)

Sandor Ferenczi(1873-1933)

Born in 1873 in Miskolc, Hungary, Ferenczi met Freud in 1908, thus beginning an intimate and often stormy 25-year relationship as Freud’s disciple, analysand, and colleague that ended with Ferenczi’s death of pernicious anemia in 1933.

Sensitive to issues of power, abuse, and trauma, Ferenczi emphasized the therapeutic importance of a holding environment, tenderness, nurturance, and a corrective emotional experience.

Sandor Ferenczi(1873-1933)

Always controversial, Ferenczi has been referred to as the “mother of psychoanalysis” and the “lovable analyst” but also as the “enfant terrible” of analysis.

Sandor Ferenczi(1873-1933)

Ferenczi’s legacy rests on his early descriptions of important clinical phenomena, including:

“identification with the aggressor” (anticipating Anna Freud),

the “holding environment” (anticipating Donald W. Winnicott),

the “corrective emotional experience”(anticipating Franz Alexander),

and fragmented self-states (anticipating Heinz Kohut).

When Anna Freud arrived in London in 1938, conflicts emerged between her and Melanie Klein regarding developmental theories of children.

Anna studied children deprived of parental care because of the war, emphasized the importance of the ego, the concept of defense mechanism.

Anna Freud (Vienna 1895- London1982)

Birth of “Middle group” of the BPS

During WWII, the followers of Anna Freud were battling those of Melanie Klein for the right to be called Sigmund Freud's true intellectual heirs.

By the end of the War, a compromise established three more-or-less amicable groups in psychoanalysis: the Freudians,

the Kleinians,

the "Middle Group“ (later called the "Independent Group"), to which Winnicott belonged, along with Ronald Fairbairn, Michael Balint, Masud Khan, John Bowlby, and Margaret Little.

The developmental model of the British school

John Bowlby (1907-1990), interested in Anna Freud work on evacuees and Rene Spitz on orphans (Marie Ainsworth was his student) became an analyst in 1937

Melanie Klein was his supervisor and his theories were rejected by psychoanalyst

The developmental model of the British school

In 1951, he published a seminal/controversial paper “Maternal care and mental health” in 1951 . Its conclusion :” the infant and young children should experience a warm intimate and continuous relationship with his mother (or substitute) in which both find satisfaction and enjoyment”

Donald Woods Winnicott (1896-1971)

English pediatrician, psychiatrist, and psychoanalyst.

Pre-med studies in 1914 interrupted by the war.

In 1917, he began medical studies at St Bartholomew's Hospital Medical College in London.

During this time, he learned from his mentor the art of listening carefully when taking medical histories from patients, a skill that he would later identify as foundational to his practice as a psychoanalyst

Donald Woods Winnicott (1896-1971)

His theoretical writings emphasized empathy, imagination, and, "the highly particular transactions that constitute love between two imperfect people."

A prime example of this is his ideal of the "good-enough mother," whereby the imperfectly attentive mother does a better job than the "perfect" one, who risks stifling her child's development as a separate being.

Donald Woods Winnicott Major Concepts: Early development

According to Winnicott, a newborn child exists in a stream of unintegrated, comfortably unconnected moments.

This existence is pleasant and not terrifying for the child.

Donald Woods Winnicott Major Concepts: Early development

These early experiences are crucial to a proper development of personhood.

The person responsible, for providing this framework is the mother, and if this environment is not provided by her, the deficiencies will manifest themselves later in the child’s life.

Donald Woods Winnicott Major Concepts: Holding environment

For the consolidation of a healthy self of an infant it is crucial that the mother is there when needed.

But even more important consequences arise when she recedes when she is not needed.

Holding environment is a psychical and physical space within which the infant is protected without knowing he is protected.

Donald Woods Winnicott Major Concepts: maternal preoccupation

When a baby is born, the mother is extremely occupied with the infant.

Under optimal circumstances the mother moves away from this state of maternal preoccupation and therefore provides an environment in which the infant is free to move and learn through experience.

For the infant it means that it begins to realize that there is an outside world (objective reality) which is not always there to fulfill his desires.

He has never observed feelings of dependency before, as his mother was always there for him. And there are also other people with their desires and agendas which can be in contradiction with his.

Donald Woods Winnicott Major Concepts: subjective omnipotence.

During this progress, the child experiences a phase Winnicott referred to as subjective omnipotence.

This experience takes place at the time when the mother-child relationship is entirely symbiotic, and the child experiences everything subjectively.

At this point the baby feels as if it is merged with the mother.

The baby considers his or herself all-powerful and the center of existence.

Donald Woods Winnicott Major Concepts

This primary maternal preoccupation means that the mother adapts her entire existence and subsequent behavior to whatever the baby expresses as a wish or desire. Because the mother’s state allows her to be so responsive, the baby experiences a moment of illusion, as Winnicott calls it. The moment of illusion, is the infant’s belief that, based on his experience, his wish for the object created exactly that object.

Donald Woods Winnicott Major Concepts: objective reality

Progressively, the mother begins to

recede as she becomes interested

in her own personhood.

Winnicott felt that this was an essential stage that leads to the child realizing that he or she is not omnipotent as believed during the subjective omnipotence phase.

It is at this point that the baby learns he or she is dependent on his or her mother and that there are other people coexisting with him or her.

Donald Woods Winnicott Major Concepts: objective reality

The child experiences this stage in such a way that Winnicott entitled it objective reality.

During objective reality the child becomes aware that the object, mainly his mother, he relates to is separate and not within his or her realm of control

Donald Woods Winnicott Major Concepts: transitional e & o

The middle ground between objective reality (alternatively referred to in literature as the “not-me”) and subjective omnipotence (alternatively the “me”) is what Winnicott called the transitional experience.

This experience is a transitional zone between the self and the real world.

Donald Woods Winnicott Major Concepts: transitional e & o

Central in the transitional experience is the transitional object that inhabits this zone, which to the infant represents the mother or her breast when she is absent.

This object can alternatively be referred to as the first “not-me” possession; a teddy bear, a blanket, etc.

Donald Woods Winnicott Major Concepts: transitional object

The child does not experience this object as created by him or herself nor as entirely detached but instead the transitional object is a fantasy.

It is a way for the child to maintain a connection to the mother while she progressively distances herself.

According to Winnicott, this experience is marked by anxiety and it is important for the child to have an object as a defense to this anxiety.

Donald Woods Winnicott “there is not such thing as a baby”

Winnicott asserted that “there is no such thing as a baby - only a nursing couple”.

He clearly stated that the inherited potential of an infant cannot become an infant, unless linked to maternal care.

Donald Woods Winnicott “the good enough mother”

The good-enough mother is a mother whose conscious and unconscious physical and emotional attunement to her baby adapts to her baby appropriately at differing stages of infancy, thus allowing an optimal environment for the healthy establishment of a separate being, eventually capable of mature object relations.

Winnicott sees the key role of the good-enough motheras adaptation to the baby, thus giving it a sense of control, subjective omnipotence and the comfort of being connected with the mother.

Donald Woods Winnicott “the good enough mother”

Furthermore, the mother can be viewed as a container for the infant's bad objects, as the child projects these into the mother.

A critical ability for her is in accepting and surviving this onslaught with equanimity.

This holding environment allows the infant to transition at its own rate to a more autonomous position.

Donald Woods Winnicott Major Concepts: True self

“Only the true self can be creative and only the true self can feel real”

For Winnicott, the True self is the instinctive core of the personality, the infant's capacity to recognize and enact its spontaneous needs for self-expression.

A True self that has a sense of integrity, of connected wholeness.

This spontaneous self and this experience of aliveness is the heart of authenticity.

Donald Woods Winnicott Major Concepts: False self

The compliant False Self reacts to environmental demands and the infant seems to accept them. Through this False Self the infant builds up a false set of relationships, and by means of introjections even attains a show of being real, so that the child may grow up to be just like mother, nurse, aunt, brother, or whoever at the time dominates the scene.

Donald Woods Winnicott Major Concepts: False self

The primary function of the False self is defensive, to protect the True self from threat, wounding, or even destruction.

This is an unconscious process: the False self comes to be mistaken for the true self to others, and even to the self.

Even with the appearance of success, and of social gains, there will also be unreality feelings, the sense of not really being alive, that happiness doesn't, or can't really exist.

Michael Balint(1896, Budapest- 1970, Bristol)

MD Budapest (1918) Start reading Freud in 1905 then attended the lectures of

Sándor Ferenczi, who in 1919 became the world's first university professor of psycho analysis.

In 1924 he returned to Budapest In 1949 Bálint met his future wife Enid Flora Eichholz, who worked in the Tavistock Institute of Human Relations with a group of social workers and psychologists on the idea of investigating marital problems.

Michael Balint became the leader of this group and together they develop what is now known as the Balintgroup.

Michael Balint

The focus of the work is on doctor-patient relationship: what it meant, how it could be used helpfully.

The MD are invited to present cases from their practice and these would be discussed by the seminar members under the guidance of one or two leaders (psychoanalyst)

The Balint societies were organized in many Europeans countries. In the US “American Balint Society (americanbalintsociety.org ) is still active

Wilfred Bion (1897-1979)

Analyzed by Melanie Klein

Associated with the Tavistock Institute

Experience in groups (1961)

Alpha elements, beta elements,(undigested fact, impressions and sensations ) alpha function (1963)

President of British psychoanalytical society from 1962-1965

Spent his later years in Los Angeles before returning

to the UK shortly before his death

Wilfred Bion (1897-1979) Alpha elements,

beta elements (undigested fact, impressions and sensations )

alpha function (1963)

For Bion thoughts exist prior to the development of apparatus for thinking; the apparatus for thinking, the capacity to have thoughts “has to be called into existence to cope with thoughts (1967).

Thoughts exist prior their realization.

Thinking, the capacity to think thoughts which already exist, develop through another mind providing alpha-function

Mary Ainsworth (1913 – 1999) American developmental psychologist known for her

work in early emotional attachment with "The Strange Situation" as well as her work in the development of Attachment Theory

Ph.D in Psychology in 1939 (University of Toronto). She stayed to teach for a few years before joining the Canadian Women's Army Corp in 1942 in World War II

Mary Ainsworth (1913 – 1999)

In 1954, she left Tavistock Clinic to do research in Africa, where she carried out her longitudinal field study of mother-infant interaction.

She and her colleagues developed the Strange Situation Procedure, which is a widely used, well researched and validated, method of assessing an infant's pattern and style of attachment to a caregiver. College.

A strange Situation

In this procedure the child is observed playing for 20 minutes while caregivers and strangers enter and leave the room, recreating the flow of the familiar and unfamiliar presence in most children's lives.

TO SEE EXAMPLES OF ‘THE STRANGE SITUATION’ GO TO THE YOU TUBE

VIDEOS ON THE SITE

A strange Situation

The situation varies in stressfulness and the child's responses are observed. The child experiences the following situations:

Parent and infant are introduced to the experimental room.

Parent and infant are alone. Parent does not participate while infant explores.

Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.

A strange Situation

First separation episode: Stranger's behavior is geared to that of infant.

First reunion episode: Parent greets and comforts infant, then leaves again.

Second separation episode: Infant is alone.

Continuation of second separation episode: Stranger enters and gears behavior to that of infant.

Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.

A strange Situation

Two aspects of the child's behavior are observed:

The amount of exploration (e.g. playing with new toys) the child engages in throughout.

The child's reactions to the departure and return of its caregiver.

On the basis of their behaviors, the children can be categorized into three groups. Each of these groups reflects a different kind of attachment relationship with the caregiver.

Secure attachment

A child who is securely attached to its mother will explore freely while the mother is present, will engage with strangers, will be visibly upset when the mother departs, and happy to see the mother return. Will not engage with stranger if mother is not in the room.

Secure attachment Securely attached children are best able to explore

when they have the knowledge of a secure base to return to in times of need.

When assistance is given, this bolsters the sense of security and also, assuming the mother's assistance is helpful, educates the child in how to cope with the same problem in the future.

Therefore, secure attachment can be seen as the most adaptive attachment style.

Secure attachment

According to some psychological researchers, a child becomes securely attached when the mother is available and able to meet the needs of the child in a responsive and appropriate manner. Others have pointed out that there are also other determinants of the child's attachment, and that behavior of the parent may in turn be influenced by the child's behavior.

Anxious-ambivalent insecure attachment

A child with an anxious-resistant attachment style is anxious of exploration and of strangers, even when the mother is present. When the mother departs, the child is extremely distressed. The child will be ambivalent when she returns - seeking to remain close to the mother but resentful, and also resistant when the mother initiates attention. When reunited with the mother, the baby may also hit or push his mother when she approaches and fail to cling to her when she picks him up.

Anxious-ambivalent insecure attachment

According to some psychological researchers, this style develops from a mothering style which is engaged but on the mother's own terms. That is, sometimes the child's needs are ignored until some other activity is completed and that attention is sometimes given to the child more through the needs of the parent than from the child's initiation.

Anxious-avoidant insecure attachment

A child with an anxious-avoidant attachment style will avoid or ignore the mother - showing little emotion when the mother departs or returns. The child may run away from his mother when she approaches and fail to cling to her when she picks him up. The child will not explore very much regardless of who is there. Strangers will not be treated much differently from the mother. There is not much emotional range displayed regardless of who is in the room or if it is empty.

Anxious-avoidant insecure attachment

This style of attachment develops from a mothering style which is more disengaged. The child's needs are frequently not met and the child comes to believe that communication of needs has no influence on the mother

Margaret Schönberger Mahler (1897 Hungary-1985 NY USA)

Hungarian physician, she later get interested in psychiatry.

Her main interest was in normal childhood development, but she spent much of her time with psychiatric children and how they arrive at the "self.

" Mahler developed the Separation-Individuation theory of child development.

Concepts

Mahler initiated a more constructive exploration of severe disturbances in childhood and emphasized the importance of the environment on the child.

She was especially interested in mother-infant duality and carefully documented the impact of early separations of children from their mothers.

Mahler’s theory: child development phases

Normal Autistic Phase –

First few weeks of life. The infant is detached and self absorbed.

Spends most of his/her time sleeping.

Mahler later abandoned this phase, based on new findings from her infant research. She believed it to be non-existent.

The phase still appears in many books on her theories.

Mahler’s theory: child development phases

Normal Symbiotic Phase –

Lasts until about 5 months of age. The child is now aware of his/her mother but there is not a sense of individuality.

The infant and the mother are one, and there is a barrier between them and the rest of the world.

Mahler’s theory: child development phases

Separation-Individuation Phase –

The arrival of this phase marks the end of the Normal Symbiotic Phase.

Separation refers to the development of limits,thedifferentiation between the infant and the mother, whereas individuation refers to the development of the infant's ego, sense of identity, and cognitive abilities.

Mahler explains how a child with the age of a few months breaks out of an “autistic shell” into the world with human connections.

Separation-individuation sub phases

The process, labeled separation-individuation, is divided into sub phases, each with its own onset, outcomes and risks.

The following sub phases proceed in this order but overlap considerably.

Hatching

Practicing

Rapprochement

Object Constancy

Object Constancy The phase when the child understands that the

mother has a separate identity and is truly a separate individual.

This leads to the formation of Internalization, which the internal representation that the child has formed of the mother.

This Internalization is what provides the child with an image that helps supply them with an unconscious level of guiding support and comfort from their mothers.

Deficiencies in positive Internalization could possibly lead to a sense of insecurity and low self esteem issues in adulthood.

Object constancy is usually defined as the capacity to see and relate to the other as a person in his or her own right.

This capacity is part of the quality of the Personal Essence, of being personal and able to make direct personal contact.

Rene Spitz Vienna 1887-Denver 1974

PLEASE CHECK THE YOU TUBE VIDEOS FOR SPITZ

http://www.youtube.com/watch?v=VvdOe10vrs4

After finishing his medical studies in 1910 (Hungary) Spitz discovered the work of Sigmund Freud.

In 1932 he left Austria and settled in Paris for the next six years.

In 1939 he emigrated to the United States and worked as a psychiatrist at the Mount Sinai hospital from 1940 until 1943, Spitz served as a visiting professor at several universities before settling in Colorado.

Spitz Rene

In 1935 that Spitz turned to the area of child development.

He was one of the first researchers who used child observation. Not only disturbed children found his interest, but he also focused on the normal child development.

He pointed out the effects of maternal and emotional deprivation. This became the field of his greatest contributions.

Spitz Rene Spitz valued several aspects: Infant observation and

assessment, anaclitic depression, hospitalism, developmental transitions, the processes of affective communication, and understanding developmental complexity.

Spitz developed the term ‘anaclitic depression’ for partial emotional deprivation (the loss of a loved object). When the love object is returned to the child within a period of three to five months, recovery is prompt. If one deprives a child longer than five months, they will show the symptoms of increasingly serious deterioration. He called this total deprivation (hospitalism).

Rene Spitz

In 1945 he did research on hospitalism in children in a foundling home. He found that the developmental imbalance caused by the unfavorable environmental conditions during the children’s first year produces a psychosomatic damage that cannot be repaired by normal measures. An other study of Spitz showed that under favorable circumstances and adequate organization a positive child development can be achieved. He stated that the methods in foundling homes should therefore be carefully evaluated.

Rene Spitz

Spitz recorded his research on film. The film Psychogenic Disease in Infancy (1952) shows the effects of emotional and maternal deprivation on attachment.

The film was the cause of major change, especially in childcare sections of institutes, homes and hospitals, due to the fact that people gained knowledge about the impact of deprivation on child development.

Harlow 1905-1981

American psychologist best known for his maternal-separation and social isolation experiments on rhesus monkeys, which demonstrated the importance of care-giving and companionship in social and cognitive development.

He conducted most of his research at the University of Wisconsin-Madison, where humanistic psychologist Abraham Maslow worked for a time with him.

Harlow 1905-1981

In a well-known series of experiments conducted between 1957 and 1963, Harlow removed baby rhesus monkeys from their mothers, and offered them a choice between two surrogate mothers, one made of terrycloth, the other of wire.

PLEASE CHECK THE Harlow videos on the You tube videos referred to on this web page

Harlow 1905-1981 Harlow's experiments were controversial; they

included rearing infant macaques in isolation chambers for up to 24 months, from which they emerged severely disturbed.

Some researchers cited the experiments as a factor in the rise of the animal liberation movement in the United States.

William Fairbairn The splitting of the ego

Fairbairn envisioned the child with largely unavailable parents as differentiating between the responsive aspects of the parents (the good object) and the unresponsive aspects (the unsatisfying object).

The child internalizes the unresponsive aspects of the parents and fantasizes those features as being a part of him, because they are not available in reality.

This defense mechanism is known as "splitting of the ego", where the good and the bad parts of the parents are kept apart, and where there is no possibility to feel ambivalence.

For example, when a mother is depressed and denies this, the child is unable to connect completely to his mother. Therefore, the child identifies itself with this denied part of the parent, and becomes depressed itself.

Fairbairn's works include: Psychoanalytical Studies of the Personality (1952) and From Instinct to Self: Selected Papers of W. R. D. Fairbairn (1994)

William Fairbairn (1889 – 1964)

On the basis of his writings he became an associate member of the British Psychoanalytical Society in 1931, becoming a full member in 1939. Fairbairn, though somewhat isolated in that he spent his entire career in Edinburgh had a profound influence on British object relations and the relational schools.

One of the most important contributions of Fairbairn to the psychoanalytic paradigm is proposing an alternative viewpoint regarding the libido. Whereas Freud assumed that the libido is pleasure seeking, Fairbairn thought of the libido as object seeking. That is, he thought that the libido is not primarily aimed at pleasure, but at making relationships with others.

Fairbairn andObject/Object relation

Fairbairn (1889-1965) disagreed with Freudian theory, and argued that the libido is not primarily aimed at pleasure but at making relationships with others

The first connections a child makes are with his parents. Through diverse forms of contact between the child and his parents a bond between them is formed, and the child becomes strongly attached to his parents.

This early relationship shapes the emotional life of the child in such a strong way that it determines the emotional experiences the child will have later on in life, because the early libidinal objects become the prototypes for all later experience of connection with others. This is the basis of Fairbairn’s object-relations theory.

Fairbairn Internal object relation

Fairbairn states that the objects a child has on a very early stage of life become the child’s prototypes for all later experiences regarding connections with others.

The internal object relation describes a relation which exists in the person's mind.

In the normal situation, healthy parenting results in a child with an outward orientation towards real people, who can give real contact and exchange. When the needs of the child are not met by the parents, e.g. dependency needs and the need for affirmative interactions, a pathological turning away from external reality takes place. Instead of actual exchange with others, fantasied, private presences are established, the so-called internal objects. To these internal objects the child relates in fantasied connections, the internal object relations.

Others names… Margaret Mead (1901-1978 USA) American cultural

anthropologist, who both was a popularizer of the insights of anthropology into modern American and Western culture, and also a respected, if controversial, academic anthropologist.

Daniel N. Stern (August 16, 1934 in New York City) is a prominent psychoanalytic theorist, specializing in infant development. He is the author of a number of books on the subject, notably The Interpersonal World of the Infant (1985).

Françoise Dolto ( 1908–1988 ) – A psychologist with a certain type of charisma, due to her sense of humor and talent, that revolutionized the domain of child-psychotherapy and mother-baby dyad

RecapObject/Object relation Objects are initially comprehended in the infant mind by their

functions and are termed "part objects".

The breast that feeds the hungry infant is the "good breast." The hungry infant that finds no breast is in relation to the "bad breast.“

Through repeated experience, internal objects are formed by the patterns emerging in one's subjective experience of the care taking environment.

These internalized images may or may not be accurate representations of the actual, external others.

With a "good enough" "facilitating environment" part object functions eventually transform into a comprehension of whole objects, which corresponds with the ability to tolerate ambiguity and to see that both the "good" and the "bad" breast are a part of the same "mommy."